Debating the Ethical Implications of the Affordable Care Act

Obama health policy advisor dismisses rumors about death panels and rationing as 'bunk.'

Dr. Ezekiel Emanuel, professor and chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania.

Discussions about the Affordable Care Act (ACA) typically revolve around implementation issues like insurance exchanges, but a group of healthcare professionals gathered Monday to discuss the ethical issues raised by the landmark legislation.

Some critics of the ACA argue that the controversial individual mandate -- which requires American who meet certain criteria to purchase health insurance -- is unethical.

The Sixteenth Biomedical Ethics Symposium was held at Hackensack University Medical Center.

Dr. Ezekiel Emanuel, a health policy advisor to President Barack Obama, argued that individuals have a "moral duty " to at least have insurance that covers emergency care.

He also introduced a statistic that some would not expect to find in a discussion of medical ethics.

"Insurance rates are higher because of the uninsured. Uncompensated care in 2008 was $27 billion in the United States, three quarters of that was picked up by the taxpayers," he said.

Further, Emanuel pointed out that the government has a history of requiring people to do things that promote public health, such as being vaccinated against certain diseases.

Emanuel dismissed critics of the ACA, sometimes referred to as "Obamacare," who have cited ethical issues regarding death panels and rationing. "The charge that Obamacare has to have rationing because there's no way to control the cost without it, that's bunk," he said.

The Affordable Care Act was signed into law in March of 2010 and will take effect in 2014.

Emanuel, who is a professor and the chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania, said that not only is the ACA ethical and moral, but also that providing a framework so that everyone in America gets coverage makes sense.

"Eventually everyone is going to need healthcare," he said.

On the ethical issue of whether the government should be involved in healthcare at all, Dr. Melvin Polkow, cochair of the biomedical ethics committee at Hackensack UMC, pointed out that millions of people are already excluded from healthcare insurance.

"How do we approach the question of the basic minimum levels of care? Do we provide equal care? We don't know. Will it become a multitiered society regarding healthcare, we do that already," said Polkow.

Polkow posed the question: "What ethical principals could be used to decide the allocations of these scarce resources?"

Emanuel also addressed the cost of implementing the ACA, which many critics say will be overburdening. The law, he explained, will initiate a variety of new payment techniques and push for more coordinated care -- especially for patients with chronic illnesses. "The Affordable Care Act will result in less unnecessary services, fewer medial errors, and fewer hospital acquired infections," Emanuel said.

In addition, under the ACA Emanuel said that everyone would have an electronic health record. "We'll have a very improved system galvanized by the ACA."

Preventing People From Getting Sicker

Emanuel told a packed audience of mostly physicians, nurses, and other medical professionals that the key to saving money is prevention. "Not primary prevention like vaccines, that’s healthy people and preventing them from getting sick. I'm talking about sick people who have a diagnosis and preventing them from getting sicker."

He said that tertiary prevention keeps people with chronic illness healthier and out of the emergency room and the hospital. Under our current system, Emanuel explained, unless uninsured individuals pay out of pocket the expenses are passed on to others.

Emanuel said that the transition to the ACA would not be smooth. "Between now and 2020 it will be bumpy. We will have ups and downs. But by 2020 we are going to be thankful we went through this transition. The system is going to be tremendously better."

When asked whether or not the Obama administration has done enough to promote the facts about the ACA and dispel negative rumors, Emanuel said that there were groups that have created a lot of disinformation about ACA -- including false claims. "That has been a serious problem. We can always do a better job at communication."

Anthony Vecchione is a freelance health/medical writer based in Dumont, NJ.